Presented by the Commission on Accreditation for Respiratory Care Susan P Pilbeam, MS, RRT, FAARC St. Augustine, FL Within the past 12 months I have worked as a consultant for Maquet, Inc. Describe faculty and student perspective on what is important to teach/learn about mechanical ventilation. Identify essential concepts that students need to understand in relation to the application of mechanical ventilation. Review relevant behaviors related to medical care. Discuss how educators and students might maintain competency. www.alumniblog.mayo.edu/people/al umni-profiles Dr. Helmholz was born in Indiana in December, 1911. Rochester, age 10 His father, Henry F. Helmholz, M.D., was asked by Dr. William Mayo to develop pediatrics at Mayo Clinic. At Mayo, Dr. Helmholz’s interest in human physiology began, and he pursued his medical education. After medical school, Fred returned to Rochester Fellow in Physiology and Pathology for the Mayo Foundation, in the Physiology Institute. Dr. Helmholz studied decompression chambers Dr. Helmholz put himself into an oxygen chamber with the equivalent of 40,000 feet in altitude. “I promptly passed out and there was much venting and letting air into the chamber to resuscitate me. “I learned that, at 40,000 feet, unless I purposely hyperventilate or over breathe, I can’t stay conscious even breathing pure oxygen. “So I learned something about myself that I could apply to aviators.” Then Second World War began WW II worked at Consolidated Aircraft Corporation in San Diego. and developed a way for B24 bomber pilots to safely fly at 35,000 feet Dr. Helmholz’s most lasting impact -- his work with respiratory therapists, locally and nationally. “I had some friends …who were kind of interested in getting an organization, the American Association of Inhalation Therapy, the AAIT… “so I worked with them and that’s how my interest in respiratory care [grew].” Dr. Helmholz early chairman and participant in the Joint Review Commission for Inhalation Therapy (JRCRTE) Now the Commission on Accreditation for Respiratory Care Appointed to the NBRC and served as one of its presidents. He retired in 1978, but continued to remain active with the CoARC and the NBRC and also the Sputum Bowl. He died in 2012. He was 100 years old. Responses from schools and hospitals in Maine, Florida, Louisiana, Texas, Georgia “As a faculty member who teachings mechanical ventilation: “What do you think is most important in teaching or learning mechanical ventilation? “And second, what techniques are the best way to teach mechanical ventilation? Consensus Items: Modes of Ventilation (4 of 8) Graphics (2 of 8) Lung protective strategies Troubleshooting Weaning process and parameters Learning basic physiology of the lungs such as compliance and resistance and effects of PPV on organ systems. Initial settings for normal and COPD How to control sensitivity and adjust to patient Learning how to assess the patients needs in terms of the goals of mechanical ventilation, - safety, comfort, and liberation. Teaching how to identify the technological capabilities available to meet those needs Teaching how to match the available technology to the needs. Be sure graduate know how to recognize respiratory distress. This is key to their function as RTs Identify the problem before the patient codes. Patient Safety Team work Compassion Effective communication Posting signs Robert M Kacmarek, Respir. Care, 2013; 58(6) pg 1087-1092 The RT has to be knowledgeable of the limits of ventilatory support and competent in identifying, via waveform analysis, patientventilator asynchrony, since asynchrony has been associated with patient outcome. “Flow, volume, and airway pressure waveforms are valuable real-time tools in identifying various aspects of patientventilator interaction.” However, “If you aren’t looking for something, you surely will not to find it.” Columbo, et al, CCM 2011, 39:11 Columbo, et al, CCM 2011, 39:11 Columbo, et al, CCM 2011, 39:11 Columbo, et al, CCM 2011, 39:11 Columbo, et al, CCM 2011, 39:11 As a faculty member who teachings mechanical ventilation, the second question: What techniques are the best way to teach MV? Lectures with case studies (3 responses) Simulations (mannequins) (2 responses) Regular lab with vents and case studies (3 responses) Labs with repetition of graphics (1 response) Inservice from ventilator representative (1response) Clinical rotations (1 response) “I would have to say, however, that I think the most effective strategy occurs when they have to breath on the ventilator connected to a mouth piece with an HME so they experience the ventilator settings.” Two faculty mentioned this. "As you were taking your mechanical ventilation classes, labs and clinicals, “…what did you find to be the top 3 most important things that helped you understand the application of mechanical ventilation in the clinical setting?" (please list in order of importance). Total of 13 responses Very limited agreement on what they perceive as important. INDIVIDUAL RESPONSES 1. Understanding the concepts of each ventilator settings 2. Comprehension and explanation of wave forms 3. Troubleshooting and ventilator changes Lecture, Lab, Inservice from vent reps Boxes, Tables and Cases (1) Paying attention and TAKING NOTES during lecture. Including drawing my own scalars and graphs. (2) Patients being mechanically ventilated. It is important to see the application of different modes and how they correlate with different pathologies as well as seeing the results in real time. (3) Handling several different ventilators in lab and learning each of their basic modes and functions. (1) Visualizing the ventilator graphics in classseeing examples of the scalars on the different modes was by far and away the best way for me to truly grasp the principles of the modes and how they apply to disease processes. (2) Use of ventilators on actual patients in the hospitals. (3) The textbook and supplemental readingreading, on my own, and having time to interpret and compare the modes (1) The way the information linked what was happening physiologically with the patient and making appropriate vent changes to compensate. (2) The hands on exposure (labs) with vents, mannequins and other equipment was invaluable. Also being able to physically do certain procedures on real patients in clinicals was a great confidence builder. (3) Trending of pulse oximetry, labs, ABGs, x-rays, ascultation etc were also helpful in understanding and following the various stages of a patient's condition and vent manipulation. The concepts of transducers and electrical physics as applied to how a mechanical ventilator works. Modes that are not presently used in a clinical setting. (3 responses) The time spent on learning all the outdated ventilators which we no longer use, or even see in the hospital and more time devoted to current applications. (2 responses) Working in groups with the ventilators. The lab activities are confusing and hard to follow. Every resource provided to me during the course has been valuable. Oscillators Most responded that they felt they were prepared I feel comfortable being in the ICU with another therapist but I am not comfortable being alone because I tend to panic in certain situations when the patient appears to be under distress (like when waking up from sedation and starting to fight the vent). by Robert M Kacmarek, Respir. Care, 2013; 58(6) pg 1087-1092 AARC “2015 and Beyond” task force. Individual RTs must be highly competent in a number of areas. They must be experts in mechanical ventilation All technical aspects of the mechanical ventilator Indications for and pathophysiology requiring mechanical ventilation Independent application of mechanical ventilation Pharmacology of critical care Adjuncts to mechanical ventilation (aerosolized pulmonary vasodilators, prone positioning, non-conventional forms of ventilatory support Modes of mechanical ventilation Disease specific management approaches Effects of application on the cardiopulmonary system Waveform analysis Identification and correction of asynchrony Provision of lung-protective ventilation The independent management of ventilatory support by protocols, guidelines, or standard order sets. A Technical expert in every aspect of mechanical ventilation. Capable of comparing the capabilities of one ventilator to another. Discuss mechanism of action of all modes and adjuncts that exist on the mechanical ventilator Monitoring and data trending “They should be the individual whom all other professions seek out when questions in this area arise.” (Kacmarek, 2013 RC) Limited brain attention span The human brain can only focus on one thing at a time Faculty and Graduates Educational conferences Literature Clinical skills: how up-to-date do you need to be? Ventilator manufacturers and their representatives How do graduates and practicing therapists manage? Recognition that a Respiratory Therapist is a professional. Knowing when to get help Learning to work as a team Keeping everybody safe Critically evaluating medical literature Sharing what they learn Being compassionate Communicating effectively Staying motivated By Dr. Stephen Sinatra, M.D. Cardiologist Dr. Jonny Bowden, Ph.D. Nutritionist True or false – lowering cholesterol reduces the incidence of heart attack. True or false – people with cholesterol values more than 260 mg/dL are more likely to die. True or false – statins reduce cholesterol levels. Triglyceride to HDL ratio Example: 150 mg/dL: 50mg/dL = 3 Harvard publication Circulation Those with the highest risk of myocardial infarction had the highest triglyceride-toHDL ratio. Gaziano JM, et al Circulation 96, 1997, 2520 Parent molecule for sex hormones A cholesterol level of 160 mg/dL or less has been linked to depression, aggression, cerebral hemorrhage and loss of sex drive We make vitamin D from cholesterol Only a problem when it is oxidized The true cause of heart disease is inflammation. There is a better relationship between sugar consumption and heart disease than fat consumption and heart disease. 2003 World Health Organization – no more than 10% of diet from all added sugars. Sugar Association annually given $406 million to the WHO. Threatened to lobby Congress to cut off the $406 million. Hypothesis: Cholesterol is a good predictor of mortality. From 1995 to 2007 Final 5 studies of 150,000 people total followed for about 5 years. (Japan Atherosclerosis and Thrombosis 14, 2007, 5.) Less than 160 mg/dL ◦ 160 to 199 mg/dL ◦ 200 to 239 mg/dL ◦ Over 240 mg/dL Current AHA guidelines: ◦ 200 mg/dL or lower desirable ◦ 201 to 239 borderline ◦ Higher than 240 is bad Those with the lowest cholesterol (<160) had the highest mortality rate (death from any cause) Rate of death decreased in highest two cholesterol groups. (200-239 & >240 mg/dL) So, are cholesterol levels just so much hocuspocus? Learn to be very critical of medical literature and the media-hype about medications. “It must be true. I saw it on the internet.” Lack of teamwork leads to medical errors and poor patient outcomes. (Dr. Martin Makary, M.D.) The key to collaborative function of any clinician in critical care is effective communication and teamwork. (Kacmarek RM, Respir Care 2013; 58:1087.) 2010 Harvard study (NEJM) As many as 25% of all patients are harmed by medical mistakes. Over the past 10 years error rates have not come down, despite efforts By Dr. Martin Makary, M.D. www.ahrq.gov/qual/patientsafetyculture 1. Is the teamwork good? 2. Would you feel comfortable having your own care performed in the unit in which you work? 3. Do people work well as a coordinated team? 4. Do doctors and nurses do what’s in the best interest for the patient? 5. Is communication strong? 6. Do you feel comfortable speaking up when you have a safety concern? Reduces incidence of errors. Teamwork survey scores correlated with infection rates and patient outcomes. Most hospitals do not want to provide this information. Government does not make public access to survey results possible. www.hospitalcompare.hhs.gov “Properly weighed data transparency would empower patients to make informed decisions about where they spend their health care dollar.” (Dr. Makary) Hospital CEOs and Medical Directors should reward employees who act on behalf of their patient-safety concerns. “At your hospital, is priority given to what’s best for the patient..” and not for what is financially best for the hospital? Humans make mistakes Less of a punishment culture? What are possible ways to reduce errors? What part of this should we teach? “Motivation just like lack of motivation spreads like wildfire.” Can you teach someone to be motivated…. That would be “No” If we don’t change the direction we are headed, we will end up where we are going.